Faculty Bibliography

PURPOSE: To report a recent significant increase of the number of patients diagnosed with Acanthamoeba keratitis (AK) at Wills Eye Hospital between 2004 and 2005. To determine the risk factors, clinical characteristics, treatments, and outcomes of patients with AK. METHODS: Retrospective consecutive case series of 20 eyes with AK. The information included the incidence from 1995 to 2005, initial and final best-corrected visual acuity (BCVA) at 3-month follow-up, risk factors [contact lenses (CL) history, history of swimming with CL, and exposure to well water and/or contaminated water], clinical characteristics, methods of diagnosis, and treatments. RESULTS: A statistically significant increased incidence of AK was seen in 2004 and 2005 compared with cases from 1995 to 2003 (P < 0.01). All patients wore CL; 19 of 20 wore frequent-replacement soft CL and used multipurpose disinfecting solutions. Other risk factors were exposure to well water in 40%, swimming with CL in 25%, and overnight wear in 25%. The diagnosis was made by histopathology in 50%, by microbiology in 15%, and by initial classic clinical signs and response to treatments in 35%. Herpes simplex virus was the misdiagnosis in 70%. Patients who presented with dendritiform keratitis or radial keratoneuritis had a BCVA better than 20/30 in 8 of 9 (89%) and patients with ring ulcers or stromal disease who had a BCVA less than finger counting in 5 of 8 (62.5%). CONCLUSIONS: We observed an increased incidence of AK. Patients with proper use of frequent-replacement CL and multipurpose solutions can develop AK. Advanced stromal disease at diagnosis is associated with worse outcome

OBJECTIVE: The aim of this study was to evaluate the prevalence of adenoviral conjunctivitis by analyzing data from a prospective clinical study of 50 consecutive patients presenting to the Wills Eye Hospital Emergency Room (WEH ER) with a clinical diagnosis of infectious conjunctivitis from July 2003 to October 2003. METHODS: The polymerase chain reaction (PCR) was used to evaluate all cases of clinically diagnosed infectious conjunctivitis. Based on the laboratory findings, the prevalence of adenovirus was determined. RESULTS: Of the 50 consecutive patients with acute infectious conjunctivitis, 31 patients were PCR positive for adenovirus. CONCLUSIONS: The prevalence of adenoviral conjunctivitis was found by PCR to represent 62% of all patients presenting with a clinical diagnosis of infectious conjunctivitis from July 2003 to October 2003

PURPOSE: To compare the incidence of herpes simplex virus (HSV) epithelial recurrence and graft survival after penetrating keratoplasty (PK) in patients with and without self-reported atopy. DESIGN: Retrospective cohort comparative study. METHODS: Setting: Cornea Service, Wills Eye Hospital. Study population: Patients who presented with previously diagnosed ocular HSV between March 2003 and March 2004 and who underwent primary PK for ocular HSV at the Cornea Service. From the 58 patients invited, 49 patients (50 eyes) were included. Nine patients were ineligible in accordance with the exclusion criteria: no active classic HSV episode before PK, immunosuppression, less than one year of follow-up, previous history of PK before presentation at the Service. Eligible patients filled out a questionnaire regarding their history of atopic disease, considering: presence of allergic rhinitis, asthma, or atopic dermatitis. Ocular history was obtained through chart review. main outcome measures: Incidence of epithelial HSV recurrences and corneal graft survival in both groups. RESULTS: Each group (atopic and nonatopic) included 25 eyes. The atopic patients had a mean incidence of 0.07 episode/eye year (SD +/- 0.9) compared with 0.12/eye year (standard deviation [SD] +/- 0.21) in the nonatopics (P = .002). At 10 years of follow-up, the survival rate in the atopics was of 92% and in the nonatopics was of 79% (P = .88). CONCLUSIONS: Nonatopics had significantly more epithelial recurrences after PK compared to atopics; however, both groups presented low incidences of recurrences and high graft survival rates

PURPOSE: To describe nine patients with fungal keratitis refractory to standard antifungal therapy whose condition was managed with voriconazole. DESIGN: Retrospective case series. METHODS: Chart review of patients with fungal keratitis who were treated with topical and oral voriconazole. RESULTS: Nine patients were treated. Two patients were contact lens wearers who used multipurpose cleaning solutions. Corneal isolates found were Fusarium (three patients), Candida albicans (three patients), Alternaria (one patient), Scopulariopsis (one patient), and Scedosporium apiospermum (one patient). Nine patients were treated with topical voriconazole, and eight patients were treated with oral voriconazole. Patients were treated topically for four to 16 weeks (mean, 10 weeks) and orally for five to 17 weeks (mean, 10 weeks). One patient was lost to follow-up. Two patients discontinued the topical voriconazole after one day and four weeks, respectively, because of ocular burning. Of the seven patients who were treated with topical therapy and followed, five conditions healed. CONCLUSION: Voriconazole is a new, promising therapy for fungal keratitis that is refractory to standard antifungal treatments

PURPOSE: To compare the efficacy of oral antiviral prophylactic treatment for herpes simplex virus (HSV) recurrences in patients with and without self-reported atopy. DESIGN: Retrospective cohort comparative study. METHODS: setting: Cornea Service, Wills Eye Hospital. study population: Patients who presented with previously diagnosed ocular HSV between March 2003 and March 2004. From 244 patients invited, 54 patients (58 eyes) were included. One hundred and ninety patients were excluded according to exclusion criteria: no active episode during follow-up, immunosuppression, less than one year of follow-up, or previous history of penetrating keratoplasty. The Questionnaire regarding history of atopic disease, considers: presence of allergic rhinitis, asthma or atopic dermatitis, and chart review of ocular history. main outcome measures: Incidence of all types of HSV recurrences with and without antiviral prophylaxis within each group and between groups. HSV episodes were classified into infectious, inflammatory, and mixed for analysis. RESULTS: Atopic/nonatopic (P value): mean follow-up without prophylaxis 8.1 (+/- 8.2)/7.3 years (+/- 8.6) (P = .71); mean follow-up with prophylaxis 2.9 (+/- 2.3)/2.6 years (+/- 2.2) (P = .51); the effect of prophylaxis significantly reduced the all recurrences in both groups except in the inflammatory recurrences in the atopic group and in the mixed recurrences in both groups. Prophylaxis decreased infectious episodes by 44% in nonatopic and 76% in atopics and decreased inflammatory manifestations by 69% in the nonatopic group and 8% in the atopic group. CONCLUSION: Antiviral prophylaxis for HSV recurrences was more effective in reducing infections in atopics and less effective in reducing inflammatory episodes in atopics versus nonatopics

PURPOSE: To compare the sensitivity, specificity, and accuracy of the RPS Adeno Detector (Rapid Pathogen Screening Inc., South Williamsport, PA) against both viral cell culture with confirmatory immunofluorescence staining (CC-IFA) and the polymerase chain reaction (PCR) for diagnosing adenoviral conjunctivitis. DESIGN: Prospective, nonrandomized, masked, multicenter clinical trial. PARTICIPANTS: One hundred eighty-six consecutive patients from 5 clinical centers seeking treatment within 1 week of developing a red eye and thought to have acute conjunctivitis. METHODS: The RPS Adeno Detector is a 10-minute in-office lateral flow immunoassay. Patients were tested with the RPS Adeno Detector, CC-IFA, and PCR to detect the presence of adenovirus. MAIN OUTCOME MEASURES: The sensitivity, specificity, and accuracy of the RPS Adeno Detector were assessed for identifying cases of adenoviral conjunctivitis. RESULTS: Compared with CC-IFA, the RPS Adeno Detector was 88% sensitive and 91% specific at detecting adenoviral conjunctivitis. Using PCR as a reference method, the sensitivity of the RPS Adeno Detector increased to 89% and the specificity increased to 94%. Compared with PCR, CC-IFA was found to be 91% as sensitive and 100% as specific. CONCLUSIONS: The RPS Adeno Detector demonstrated sufficient sensitivity and specificity to be used in the physician's office for the detection of adenoviral conjunctivitis

PURPOSE: To evaluate the relationship between topical corticosteroids and other variables and the risk for rejection after penetrating keratoplasty for keratoconus. METHODS: The records of all keratoconus patients who, after their first penetrating keratoplasty in that eye, experienced a first episode of corneal graft rejection during a specific 3-year period were retrospectively reviewed in a case-control fashion. Twenty-three cases were identified, and they were matched with 3 controls each, for a total of 69 controls and 92 total patients. Multiple variables including steroid potency, recent steroid tapering, and length of time on the current level of steroids were analyzed to see whether there were any significant relationships between postoperative changes in steroid management and rejection. In addition, other variables such as graft size, suture technique, recent suture removal, suture status at the time of the rejection episode, and prior grafting in the fellow eye were examined to determine if any of these factors were associated with a higher risk of graft rejection. RESULTS: Most of the proposed risk factors, including steroid dose and tapering, differing suturing techniques, loose and/or broken sutures at the time of rejection, percentage of sutures remaining at the time of rejection, and prior grafting in the fellow eye, did not correlate with the risk of rejection. Only graft size had a correlation, with host trephination size > or = 8.25 mm having a nearly sixfold increased risk of rejection (P = 0.015). Most patients (70%) were diagnosed with rejection at a scheduled office visit rather than at an emergency visit, and correspondingly, nearly one half (43%) had no symptoms when rejection was identified. There was no significant difference in final best-corrected visual acuities between the cases and controls, and 91% of the corneas that underwent rejection did not progress to graft failure, remaining centrally clear at most recent follow-up. CONCLUSION: In this study, the most important risk factor for rejection after corneal transplantation for keratoconus was the size of the graft. Physician detection of rejection is paramount, because a graft rejection episode is more often diagnosed at a scheduled office visit than at an emergency visit. Fortunately, progression to graft failure can usually be prevented if treatment is started promptly and intensively

PURPOSE: To compare intraocular pressure (IOP) measurements in patients with keratoconus (KC), pellucid marginal degeneration (PMD), and unilateral penetrating keratoplasty (PK) for KC by Goldmann applanation tonometry (GAT), Tono-Pen tonometry (TP), and Pascal dynamic contour tonometry (DCT). METHODS: Patients with KC, PMD, or PK were included in a prospective study. IOPs were measured by GAT, TP, and DCT. Severity of ectasia was determined by the steep curvature by corneal topography and central thinning by contact ultrasound pachymetry. IOP measurements were compared and correlated with disease severity. RESULTS: Fifty-three eyes of 36 patients were enrolled. Mean age was 45.3 +/- 12.5 years (range: 28-72 years). Twenty-nine eyes had KC, 21 eyes had a PK for KC, and 3 eyes had PMD. Mean DCT, GAT, and TP readings were 16.1 +/- 2.9, 14.3 +/- 4.1, and 13.8 +/- 4.1 mm Hg, respectively. The differences of mean IOP between GAT and DCT and TP and DCT were statistically significant, whereas the difference between GAT and TP was not. Both GAT and TP readings were significantly higher in the PK eyes than the KC and PMD eyes, whereas DCT readings were not. DCT measurements were not significantly different in PK versus non-PK eyes. CONCLUSION: DCT is a newly Food and Drug Administration (FDA)-approved device that is designed to measure IOP, independent of corneal thickness, corneal curvature, and ocular rigidity. DCT gave significantly higher IOP readings than GAT and TP in this study. DCT readings were not affected by corneal thickness. DCT may be more accurate in IOP measurement in eyes with KC and PMD